Healthcare Provider Details

I. General information

NPI: 1487140190
Provider Name (Legal Business Name): CLEAR SPACE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 MAIN ST
TOPSHAM ME
04086-1221
US

IV. Provider business mailing address

PO BOX 283
BRUNSWICK ME
04011-0283
US

V. Phone/Fax

Practice location:
  • Phone: 207-274-7765
  • Fax:
Mailing address:
  • Phone: 207-274-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CHESLEY FLOTTEN
Title or Position: OWNER
Credential: LCSW
Phone: 207-274-7765